<p> PLACE LABEL HERE DIRECT ADMISSION ORDERS</p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).</p><p>Attending Physician: ______1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?  Yes, admit as inpatient, proceed to # 2 No, place in observation 2. If admitted as inpatient, Inpatient Physician Certification: Diagnosis: ______Level of Care:  Critical  Intermediate  Acute Care Location/Specialty Unit Preference___ 3.  Telemetry: If patient Medical/Surgical, must complete form # 36084 4.  Isolation:  Contact  Droplet  Airborne For: ______5. Consults: ______6. Special needs:  Bariatric Beds (> 181.8 kg (400 lbs)  Dialysis  Sitter/1013 7. Diagnostics :  CBC  PT/PTT  TSH  CMP  Urinalysis  Troponin  CXR PA/lateral on admission, Reason______, to be read by______ EKG on admission, Reason______, to be read by______ Quantitative hCG for any menstruating female ≥ 12 y/o  Other: ______8. Vital signs per unit routine or q ____ hrs 9.  Glucose finger stick ac & hs or q ____ hrs 10 Diet:  Regular  Cardiac  Diabetic______calories  Renal  Other: ______11. Activity (advance as tolerated): Bed rest or  Up ad lib  BSC  BRP 12.  Please call Physician/Provider on arrival to the floor MEDICATION ORDERS: 13.  INT  IVF: ______IV at ______ml/hr 14. ______15. ______16. ______ADDITIONAL ORDERS: ______</p><p>______Date Time Physician Signature PID Number Copy to pharmacy </p><p>*1-39006* FORM 39006 INITIATED 08/2015 Page 1 of 1</p>